Are “Allow Natural Death” orders preferable to “Do Not Resuscitate” orders for patients with advanced cancer?

Abstract

e20685 Background: Over twenty years after the passage of the Patient Self-Determination Act, patients’ preferences regarding end-of-life (EOL) care are often unknown to physicians. The aim of this study was to assess the knowledge and attitudes of cancer patients regarding EOL care, and to compare “Do Not Resuscitate” (DNR) and “Allow Natural Death” (AND) orders. Methods: Adult patients with advanced cancer were invited to participate. The first 50 consenting patients were surveyed regarding their prognosis and attitudes about critical care and resuscitation. We presented them with hypothetical scenarios in which a decision on their code status had to be made if they had 1 year, 6 months or 1 month left to live. Twenty-five patients were given a choice between being “full code" and DNR, and then 25 patients had a choice between "full code" and AND. Results: Almost half the patients (49%) were not aware that their illness was terminal. Fifty percent reported having a living will. However, only 19% reported that their doctors knew their wishes regarding EOL care. In contrast, greater than 78% reported knowledge of intubation, tracheotomy, feeding tubes, and cardiopulmonary resuscitation (CPR). The proportions of participants choosing full resuscitation compared to the DNR or AND options did not differ significantly from 50% (p-values > 0.54). Their choices did not vary by age, sex, race, type of cancer, education or income level (p-values > 0.05). Patients' attitudes towards CPR, tracheostomy and feeding tubes were not significantly associated with their choice of "DNR" (p-values > 0.17), but those who wanted these interventions were significantly less likely to choose "AND" (p-values < 0.002). As many as 38% of the patients without a living will chose "DNR", while 11% opted for "AND" (p-values < 0.03). Conclusions: In this small sample of patients with advanced cancer many were unaware of their poor prognosis, and few informed their physicians of their EOL preferences. The wording of DNR and AND orders was not associated with patients' EOL preferences. Contrary to our expectation, the "Allow Natural Death" phrasing might be less acceptable to patients who view life-prolonging measures favorably.